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oaut'ni c°\°2' . . SA N J OA U I N Environmental Health Department " tom —COU NTY- °��IFoa��✓ Greatness grows her.. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 20633 Elliot Road City/State/Zip Lockeford, CA 95237 Phone Cross Street N/A APN 05121073 Property Owner' Crossroads Real Estate LLC (Hayden Webster) Phone 209-200-9278 Address 12686 Curry Avenue City/State/Zip Lodi, CA 95240 C-57 Contractor Environmental Control Associates (ECA) License# 695970 Phone 831-662-8178 Address 3011 Twin Palms Drive City/State/Zip Aptos, CA 95003 Consultant/Sub-contractor Partner Engineering & Science, Inc. License# Phone 774-414-3666 Address 490 43rd Street City/State/Zip Oakland, CA 94609 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 20' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ® SOILVAPOR PROBE 3 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC OTHER L(A 0 I u6 ,4 ® SOIL BORING 3 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ElNo Boring Dia: Casing Dia:I Casing Depth: ❑ INJECTION(Air Saaree.ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [XI PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs 131 through B3 GROUT SPECIFICATIONS Soil borings-to be converted to temporary SVPs. overdrilled, and grouted With neat cempnt yl8 tremmle DESTRUCTION WORK TO BE PERFORMED: DESTRIT)-MN METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED []AUGERS []HOSE []PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: +o OV�r�.�+ IV 1—v�u ( �1� Zp I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed %" Title/Company Project Manager/Partner Print Name Michel Helou Date 3/3/2026 DEPARTMENT USE ONLY Application Accepted By: / �Z �7\ Date Issued: Grout Inspection By/Dates: �1 Destruction Inspection By/Dates: Facility/Site Information FA Name - FA Address FA# PR# FA PE VIP Reviewed By Work Plan Date ❑C-57 W-57 Authorization for other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit cress Agreement ❑Lead Agency Approval FR COMMENTS/CONDITIONS: WP TYPE PE sC FEE INFO AMT REMITTED CHECK# R 'D BY DATE WELL PERMIT# INVOICE# Permit -i� v�— � $179 x '5 '�-3 v, ck— 3 -U MO 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 4,68-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 07-01-2025 7,U1 Y1-r7-P Site Mitigation Well Permit Application